Background: Routine reversal (neostigmine) and the use of quantitative monitoring of neuromuscular blockade (Train of Four Ratio (TOFR)) are recommended to prevent the occurrence of residual paralysis. This study attempted to determine the effectiveness between neostigmine partial dose 0.02 mg/kgbw and adjusted dose based on TOFR value in recovering neuromuscular blockade of single dose rocuronium 0.6 mg/kgbw.

Methods: This randomized clinical trial was performed in the operating room of Integrated Surgical Care Unit of Cipto Mangunkusumo General Hospital and Kirana Clinic. Sixty-one patients who underwent elective surgery in general anesthesia were randomized in to 2 groups: administration of neostigmine in partial dose 0.02 mg/kgbw (group A) and adjusted dose based on TOFR value (group B). Quantitative monitoring evaluation of neuromuscular blockade was performed four times: after adequate spontaneous breathing, 5, 10, and 15 minutes after reversal.

Result: The mean of TOFR values in group A and group B respectively: after spontaneous breathing 42% and 50% (p=0.436); 5 minutes after reversal 80.2% and 89.2% (p=0.083); 10 minutes after reversal 92.2% and 94% (p=0.399); 15 minutes after reversal 94.3% and 94.9% (p=0.526). After the 5 minutes of reversal, group B (80.6%) reaches TOFR value ≥ 90% many more than group A (63.3%) (p=0.132).

Conclusion: Neostigmine partial dose 0.02 mg/kgbw was as effective as administering neostigmine in adjustment dose based on TOFR values to achieve complete recovery from the neuromuscular block effect of single-dose rocuronium 0.6 mg/kgbw. This study also show the complete recovery of neuromuscular block when TOFR value ≥ 90%.
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Early Goal Directed Therapy (EGDT) protocols can still be considered to provide clear guidelines for bedside clinicians to treat sepsis. The use of EGDT protocol requires Central Venous Catheter (CVC) installation to calculate Central Venous Pressure (CVP). In the field, especially in the remote area, the installation of CVC often cannot be done because of the unavailability of tools or other reasons. Wiryana, et al. found that there was a strong negative correlation between CVP and collapsibility index of Inferior Vena Cava (IVC) and that IVC Collapsibility Index (IVC CI) could replace CVP(1), so it could be used to replace the role of CVP on modified EGDT protocol. Five patients were measured IVC diameter and IVC CI after initial fluid therapy and had an expiratory IVC diameter and a collapsibility index belonging to the CVP group of 11-15cmH2O according to Katja, et al(2).

Background: Caesarean section is one of the most commonly performed surgical operations in the world today.Caesarean section commonly induces moderate to severe pain for about 48 hours. It requires optimal perioperative pain management. Postoperative pain management is an important issue in clinic. Proper and efficient pain management is necessary during hospitalization for preventing the related complication which could affect mother and neonate health status. Recently, multimodal pain management has been tested as postoperative pain management. One of the alternatives that can be used is local infiltration analgesia (LIA) method. Local infiltration analgesia technique can provide an adequate effect of analgesia and reduced parenteral opioid consumption without any adverse effects.

Case Presentations: Cases in this study collected from Kalabahi Public Hospital, East Nusa Tenggara, Indonesia. 42 patients who met the inclusion criteria underwent caesarean section was injected with Lidocaine-Epinephrine 0.5% in abdominal muscle and subcutaneous layer as postoperative pain management. After that, the patients were observed to evaluate pain score with Visual Analog Scale (VAS), opioid consumption as the pain rescue, the level of satisfaction, and to evaluate post caesarean wound.

Conclusion : This study showed that lidocaine-epinephrine 0.5% injection reduced postoperative pain, so allowed early mobilization and reduced the nurse’s work, increased the patient’s satisfaction, and there were no report of wound complication. This study also showed the pain score of the first 24 hours was 2.095238 with standard deviation 0.878178, and just 4 patients who asked for rescue analgesic.
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Low flow anesthesia and laparoscopic technique in pediatric patients are kinds many kind of modern medical field development. Both technique were made to support environment friendly, safety, and comfortable anesthesia practice for patients. In three cases presented in this case series, laparoscopy was done in all three cases (two digestive cases, and one urology case). All three cases performed with general anesthesia by low flow anesthesia technique with volatile sevoflurane combined with caudal block regional anesthesia. In all those cases, no morbidity was found after anesthesia or operation that influence in patient’s outcome. Improvement in outcome of pediatric patients was seen with low flow anesthesia technique, which are significant reduction of volatile used, faster wake up time, and reduction of agitation condition after anesthesia.
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Anesthesiology demands a vigilant and controlled cautious person with a good tempered manner and professional character. Those virtues and values were built through thousands of trials, errors, failures, chances and breakdowns. When some individuals could resist and thrive, others may fall and surrender. Anesthesiologists are responsible of patients beneficiary with the utmost point should be considered in patient physical safety and survival. The aim to become a good anesthesiologist who keeps the safety and patient wellbeing sometimes had taken its toll by sacrificing the wellbeing of the anesthesiologists themselves.